Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study

BACKGROUND: The management of colon injuries that require resection is an unresolved issue because the existing practices are derived mainly from class III evidence. Because of the inability of any single trauma center to accumulate enough cases for meaningful statistical analysis, a multicenter prospective study was performed to compare primary anastomosis with diversion and identify the risk factors for colon-related abdominal complications. METHODS: This was a prospective study from 19 trauma centers and included patients with colon resection because of penetrating trauma, who survived at least 72 hours. Multivariate logistic regression analysis was used to compare outcomes in patients with primary anastomosis or diversion and identify independent risk factors for the development of abdominal complications. RESULTS: Two hundred ninety-seven patients fulfilled the criteria for inclusion and analysis. Overall, 197 patients (66.3%) were managed by primary anastomosis and 100 (33.7%) by diversion. The overall colon-related mortality was 1.3% (four deaths in the diversion group, no deaths in the primary anastomosis group, p = 0.012). Colon-related abdominal complications occurred in 24% of all patients (primary repair, 22%; diversion, 27%; p = 0.373). Multivariate analysis including all potential risk factors with p values < 0.2 identified three independent risk factors for abdominal complications: severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis. The type of colon management was not found to be a risk factor. Comparison of primary anastomosis with diversion using multivariate analysis adjusting for the above three identified risk factors or the risk factors previously described in the literature (shock at admission, delay > 6 hours to operating room, penetrating abdominal trauma index > 25, severe fecal contamination, and transfusion of > 6 units blood) showed no statistically significant difference in outcome. Similarly, multivariate analysis and comparison of the two methods of colon management in high-risk patients showed no difference in outcome. CONCLUSION: The surgical method of colon management after resection for penetrating trauma does not affect the incidence of abdominal complications, irrespective of associated risk factors. Severe fecal contamination, transfusion of > or = 4 units of blood within the first 24 hours, and single-agent antibiotic prophylaxis are independent risk factors for abdominal complications. In view of these findings, the reduced quality of life, and the need for a subsequent operation in colostomy patients, primary anastomosis should be considered in all such patients.     

Breast Cancer After Severe Burn Injury: Coincidence or Consequence?

Abstract:  Malignant neoplasms arising in burn scars are well known but rarely encountered. We discuss personal experience with two patients, both female, who were diagnosed with advanced breast cancer many years after severe thermal injury to their breasts. Our experience, similar to the scant previously published data, reinforces that burn scars demand a high index of suspicion for the presence of an underlying malignant neoplasm. The literature and our study suggest that breast cancer may occur after severe thermal injury. Breast lesions in this or a similar clinical scenario should be considered malignant until proven otherwise, and a tissue diagnosis must be pursued without delay.     

Severe traumatic brain injuries in children: Does the type of trauma center matter?

Background

Traumatic brain injury (TBI) is the leading cause of death among injured children. Depending on geographic location, and trauma resources, pediatric patients may be treated at pediatric (PTC), adult (ATC), or mixed trauma centers (MTC). The effect of the type of trauma center on outcomes in severe TBI is not known.

Partial or non-union after triple arthrodesis in children: does it really matter?

Purpose

Triple arthrodesis is a commonly performed salvage procedure to correct hindfoot deformity. Non-union is considered an undesirable radiographic outcome; however, the clinical ramifications of this are not as well defined. The purpose of this study was to determine the incidence of partial or complete radiographic non-union after triple arthrodesis in children and characterize the clinical consequences.

Methods

An IRB-approved retrospective review of triple arthrodesis surgeries in patients less than 16 years of age performed by a single surgeon (DSW) identified 159 cases meeting the inclusion criteria. Plain radiographs were reviewed for bony fusion (defined as over 80 % radiographic bony union of the subtalar, calcaneocuboid, and talonavicular bones) and charts for clinical outcomes (pain, return to activity, and subsequent hindfoot surgeries). Statistics were used to compare the fused and unfused cases, with p < 0.05 considered to be significant.

Results

Of the 159 cases included in the study, 9 % did not achieve at least 80 % plain film radiographic union. The fused and unfused groups had similar clinical outcomes. Only one patient required surgery for sequelae of symptoms arising from a pseudoarthrosis related to the triple arthrodesis. The fused and unfused groups were similar in terms of gender and pin removal time, but differed significantly in surgical age and underlying diagnosis.

Conclusions

This is one of the largest case series of pediatric triple arthrodesis surgery presented in the literature. This study demonstrated that good clinical outcomes can be achieved despite the lack of radiographic union after triple arthrodesis surgery in children.

Level of evidence

IV.

     

Severe mitral regurgitation in acute eosinophilic endomyocarditis: repair or replacement?

Established eosinophilic endomyocardial disease usually causes progressive heart failure from diastolic restriction and/or valvular dysfunction. Surgical treatment typically involves resection of endoventricular fibrosis and atrioventricular valve replacement. However, little is known of the clinicopathological behaviour and perioperative course of this disease in the early stages. Mitral valve repair seemingly offers an attractive surgical option in this scenario as it avoids prosthetic thrombosis--a recognized late complication of this disease. This was attempted in conjunction with left ventricular thrombectomy in a patient with acute hypereosinophilia and congestive heart failure associated with severe mitral regurgitation and restrictive cardiomyopathy. Although the early clinical and echocardiographic outcome was excellent, the patient deteriorated rapidly after 3 months when identical pathology relapsed in the left heart causing recurrent severe mitral regurgitation and heart failure. Cardiac function improved markedly following a redo bioprosthetic mitral valve replacement. Prosthetic valve function remained satisfactory until death occurred 2 months later from refractory acute lymphocytic leukaemia. Rapid disease recurrence jeopardizing a conserved mitral valve in acute eosinophilic endomyocarditis cautions against surgical repair despite its many advantages. A bioprosthesis is associated with reduced thrombotic complications and may be the treatment of choice for this rare pathology.     

Severe acute hepatic failure and haemophagocytic syndrome: cause or consequence?

Haemophagocytic syndrome corresponds to an unconnected macrophagic activity with haemophagocytosis. We report the case of a haemophagocytic syndrome in a 49-year-old woman with initially a severe acute hepatic failure. This syndrome is probably underestimated in ICU patients. Haemophagocytic syndrome should be suspected in patients with fever and jaundice without infection.     

Osteosynthesis or primary arthrodesis for displaced intra-articular calcaneus fractures Sanders type IV – A systematic review

BackgroundDisplaced intra-articular calcaneus fractures (DIACF) Sanders type IV represent a challenge in its management and questions remain about the best treatment option available. This study aimed to compare the outcomes of primary subtalar arthrodesis (PSTA) and osteosynthesis in these fractures.MethodsStudies concerning DIACF Sanders type IV, from 2005 to 2020 were systematically reviewed. Only studies evaluating functional outcomes with American Orthopaedic Foot & Ankle Society ankle-hindfoot (AOFAS) score were admitted allowing for results comparison.ResultsIn total, 9 studies met the inclusion criteria. These reported on the results of 142 patients, from which 41 submitted to PSTA and 101 to osteosynthesis, with an average follow-up period over 2 years. We found a significant moderate negative correlation between the reported AOFAS score and the Coleman Methodology Score obtained. Late subtalar arthrodesis was 13.63% of the total osteosynthesis performed.ConclusionsClinical outcomes after PSTA and osteosynthesis, for the treatment of Sanders type IV fractures, do not seem very different, yet careful data interpretation is crucial. Additional powered randomized controlled trials are necessary to assess which surgical strategy is better.     

Tibialis posterior tendon dysfunction: a primary or secondary problem?

Seventeen patients with a mean follow-up of 64.4 months following a tibialis posterior tendon transfer to regain active foot dorsiflexion were clinically examined specifically for signs of tibialis posterior tendon dysfunction. The results show that 8 patients (47%) had Grade 4 or better power of eversion but none had a clinical flatfoot on the Harris-Beath footprints. Only 6% had forefoot abduction; 17% exhibited hindfoot valgus and 82% were able to perform the single-heel rise. Tibialis posterior tendon dysfunction therefore does not appear to be an inevitable sequel of tibialis posterior tendon transfer even in the presence of a functioning peroneal muscle. Other studies have noted that a pre-existent flatfoot was often present in patients with tibialis posterior tendon dysfunction. None of the patients in this study had pre-existent flatfoot. We suggest that a predisposition, in the form of a pre-existent tendency to flatfoot may also be a factor in the pathogenesis of tibialis posterior tendon dysfunction. This may explain the long-term failure of flexor digitorum longus and flexor hallucis longus tendon transfers in the treatment for tibialis posterior tendon dysfunction when the biomechanics of the foot has not been altered.     

Which repair in umbilical hernia of adults: primary or mesh?

In classic literature, knowing that small defects can be repaired primarily in umbilical hernias of adults, mesh repair should be reserved for larger defects. Conventional repair methods have resulted in high rates of recurrence. Therefore, this prospective study investigated the repair techniques in umbilical hernias of adults. The patients who underwent primary umbilical hernia operation between 1998 and 2003 were reviewed. Primary repair was conducted in defects less than 3 cm, whereas larger defects were repaired with polypropylene mesh. Postoperative complications, the length of hospital stay, and recurrence in follow-up were recorded. Of 111 patients, primary repair was carried out on 63 patients, and 48 underwent polypropylene mesh repair. Recurrence rate was significantly higher in the primary repair group (14%) compared with polypropylene mesh repair group (2%). In conclusion, contrary to the general tendency that small defects can be repaired primarily, polypropylene mesh should be used in all umbilical hernias regardless of the size of the defect.     

Bronchoscopic palliation of primary lung cancer: Single or multimodality therapy?

Background An obstructing primary lung cancer is a challenging disease frequently requiring endobronchial interventional therapy. A variety of interventional modalities, including Nd:YAG laser, stenting, photodynamic therapy (PDT), and endoluminal brachytherapy, are utilized to relieve airway obstruction and bleeding. The aim of this study is to compare the effect on patient survival of bronchoscopic palliation for lung cancer utilizing one interventional modality compared to the use of combination of modalities to relieve the airway problem.Methods We reviewed our longitudinal experience with interventional bronchoscopy in 75 patients who underwent 176 procedures for the management of endobronchial lung cancer between 1994 and 2002. Indication for intervention was hemoptysis in 24 patients (32%) and airway obstruction in the remaining. Six patients died within 30 days from the first intervention and were excluded. Forty of the surviving 69 patients (58%) were treated with a single interventional modality (group A). In 29 patients (42%) a multimodality endoscopic treatment was utilized (group B). Single-modality treatment in group A included Nd-YAG laser in 60%, stent in 17%, brachytherapy in 20%, and PDT in 3%. A variety of combinations of the aforementioned modalities were used in group B to enhance airway patency. Patient data were compared with the Students t-test and chi-square test. Survival analysis and the log rank test were used to compare difference in survival between the two groups. A p-value of 0.05 was considered significant.Results There were 46 males and 23 females, with a mean age of 67 years. The tumor was located in the trachea 9%, in the carina in 7%, and primary bronchial in 84%. Two patients had complications due to stent malposition. There was no significant difference between the two groups in relation to age, gender, tumor location, histology, and type of previous cancer therapy. There was a significant improvement in survival for the multimodality group (p = 0.04). The 1- and 3-year cumulative survival rate for groups A and B was 51.3% versus 50% and 2.3% versus 22%, respectively.Conclusions Improvement in survival can be seen with diligent airway surveillance after interventional bronchoscopy and liberal use of a variety of endobronchial treatment modalities for airway obstruction or bleeding. Physicians involved in the management of this difficult problem should be versed in the use of all available treatment modalities to enhance therapeutic outcome.